Medicaid Incentives for Prevention of Chronic Diseases Evaluation (CMS-10477)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10477 Yearly Admin Cost Form	Form and Instruction	New	Available
Form CMS-10477 Combined Administrative Cost Form - Informed Consent	Form and Instruction	New	Available
Form CMS-10477 Survey_Spanish_new_clean	Form and Instruction	Unchanged	Available
Form CMS-10477 CATI_Script_Spanish_new_clean	Form and Instruction	Unchanged	Available
Form CMS-10477 Beneficiary survey phone follow-up for non-responders	Form and Instruction	Unchanged	Available
Form CMS-10477 Beneficiary survey questionnaire	Form and Instruction	Unchanged	Available
Form CMS-10477 Consent_Forms_Spanish_new_clean	Form and Instruction	Unchanged	Repair queued
Form CMS-10477 Participant_Contact_Release_Forms_Spanish_new_clean	Form and Instruction	Unchanged	Available
Form CMS-10477 Screener_Spanish_new_clean	Form and Instruction	Unchanged	Available
Form CMS-10477 Focus group consent form	Form and Instruction	Unchanged	Available
Form CMS-10477 Participant contact release form for focus groups	Form and Instruction	Unchanged	Repair queued
Form CMS-10477 Discussion guide for focus groups	Form and Instruction	Unchanged	Available
Form CMS-10477 Screener for focus group eligibility	Form and Instruction	Unchanged	Available
Form CMS-10477 Stakeholder interview scheduling script	Form and Instruction	Unchanged	Available
Form CMS-10477 Stakeholder interview guide and consent form	Form and Instruction	Unchanged	Available
Form CMS-10477 Physician interview verbal consent script	Form and Instruction	Unchanged	Available
Form CMS-10477 Stakeholder interview appointment reminder	Form and Instruction	Unchanged	Available
Form CMS-10477 Clinic staff interview protocol and consent	Form and Instruction	Unchanged	Available
Form CMS-10477 State evaluator interview protocol and consent	Form and Instruction	Unchanged	Available
Form CMS-10477 Staff educator interview protocol and consent	Form and Instruction	Unchanged	Available
Form CMS-10477 Recruitment staff interview protocol and consent	Form and Instruction	Unchanged	Available
Form CMS-10477 Management staff interview protocol and consent	Form and Instruction	Unchanged	Available
MIPCDSupportStatementPartB.pdf	Supporting Statement B	Uploaded 2014-10-01	Available
Attachment_6e_Reminder_Letter.pdf	Supplementary Document	Uploaded 2013-08-07	Available
Attachment_6b_Survey_Cover_Letter.pdf	Supplementary Document	Uploaded 2013-08-07	Available
Attachment_6a_Prenotification_Letter.pdf	Supplementary Document	Uploaded 2013-08-07	Available
Attachment_4c_Recruitment_Flyer_Template.pdf	Supplementary Document	Uploaded 2013-08-07	Available
Attachment_4f_Reminder_Email.pdf	Supplementary Document	Uploaded 2013-08-07	Available
Attachment_2b_Physician_Background_FAQ (revised).pdf	Supplementary Document	Uploaded 2013-08-07	Available
Attachment_2a_Physician_Interview_Email_Invitation.pdf	Supplementary Document	Uploaded 2013-08-07	Available
Attachment_5b_Interview_Email_Invitation.pdf	Supplementary Document	Uploaded 2013-08-06	Available
Attachment_5a_Background_FAQ.pdf	Supplementary Document	Uploaded 2013-08-06	Available
MIPCD_Supp_State_Part_A_06_25_2014.docx	Supporting Statement A	Uploaded 2014-10-01	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
213346	Administrative Cost Forms for MIPCD	Form and Instruction	New	Yearly Admin Cost Form
213346	Administrative Cost Forms for MIPCD	Form and Instruction	New	Combined Administrative Cost Form - Informed Consent
208113	Beneficiary Satisfaction Survey	Form and Instruction	Unchanged	Survey_Spanish_new_clean
208113	Beneficiary Satisfaction Survey	Form and Instruction	Unchanged	CATI_Script_Spanish_new_clean
208113	Beneficiary Satisfaction Survey	Form and Instruction	Unchanged	Beneficiary survey phone follow-up for non-responders
208113	Beneficiary Satisfaction Survey	Form and Instruction	Unchanged	Beneficiary survey questionnaire
208112	Focus Groups	Form and Instruction	Unchanged	Consent_Forms_Spanish_new_clean
208112	Focus Groups	Form and Instruction	Unchanged	Participant_Contact_Release_Forms_Spanish_new_clean
208112	Focus Groups	Form and Instruction	Unchanged	Screener_Spanish_new_clean
208112	Focus Groups	Form and Instruction	Unchanged	Focus group consent form
208112	Focus Groups	Form and Instruction	Unchanged	Participant contact release form for focus groups
208112	Focus Groups	Form and Instruction	Unchanged	Discussion guide for focus groups
208112	Focus Groups	Form and Instruction	Unchanged	Screener for focus group eligibility
208111	Stakeholder Interview	Form and Instruction	Unchanged	Stakeholder interview scheduling script
208111	Stakeholder Interview	Form and Instruction	Unchanged	Stakeholder interview guide and consent form
208111	Stakeholder Interview	Form and Instruction	Unchanged	Physician interview verbal consent script
208111	Stakeholder Interview	Form and Instruction	Unchanged	Stakeholder interview appointment reminder
208110	Site Visit Interviews	Form and Instruction	Unchanged	Clinic staff interview protocol and consent
208110	Site Visit Interviews	Form and Instruction	Unchanged	State evaluator interview protocol and consent
208110	Site Visit Interviews	Form and Instruction	Unchanged	Staff educator interview protocol and consent
208110	Site Visit Interviews	Form and Instruction	Unchanged	Recruitment staff interview protocol and consent
208110	Site Visit Interviews	Form and Instruction	Unchanged	Management staff interview protocol and consent

ICR Details

OMB Control No: 0938-1219	ICR Reference No: 201410-0938-001
Status: Historical Active	Previous ICR Reference No: 201308-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No: 20261
Title: Medicaid Incentives for Prevention of Chronic Diseases Evaluation (CMS-10477)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/29/2014
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/01/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2017	36 Months From Approved	01/31/2017
Responses	4,706	0	4,686
Time Burden (Hours)	2,236	0	1,836
Cost Burden (Dollars)	0	0	0

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Abstract: Section 4108 (a) (1) of the 2010 Affordable Care Act (ACA) established the Medicaid Incentive for Prevention of Chronic Disease program (MIPCD). This national demonstration awarded 10 grants to states to implement programs that provide incentives to Medicaid beneficiaries of all ages who participate in prevention programs and demonstrate changes in health risk and outcomes, including the adoption of healthy behaviors. Programs address at least one of the following prevention goals: tobacco cessation, controlling or reducing weight, lowering cholesterol, lowering blood pressure, and avoiding the onset of diabetes or in the case of a diabetic, improving the management of the condition. Programs are comprehensive, widely available, easily accessible, and based on relevant evidence-based research and resources. Under Section 4108 (d) of the Affordable Care Act, Health and Human Services Secretary through the Centers for Medicare and Medicaid Services (CMS) awarded a contract to Research Triangle Institute to conduct an independent assessment of these 10 State demonstration Grantees. This assessment will focus on evaluating:(A)the effect of the initiatives on the use of health care services by Medicaid beneficiaries participating in the program;(B)the extent to which special populations (adults with disabilities, adults with chronic illnesses, and children with special health care needs) are able to participate in the program; (C)the level of satisfaction of Medicaid beneficiaries with respect to the accessibility and quality of health care services provided through the program; and(D)the administrative costs incurred by State agencies that are responsible for administration of the program. To address these topics we will be conducting Site Visits, Stakeholder Interviews, Focus Groups, Beneficiary Survey and Administrative Cost Forms.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 4108 Name of Law: Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 4108 Name of Law: Affordable Care Act

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 42018	07/18/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 57932	09/26/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
Administrative Cost Forms for MIPCD	CMS-10477, CMS-10477	Combined Administrative Cost Form - Informed Consent ,   Yearly Admin Cost Form
Beneficiary Satisfaction Survey	CMS-10477, CMS-10477, CMS-10477, CMS-10477	Beneficiary survey questionnaire ,   Beneficiary survey phone follow-up for non-responders ,   CATI_Script_Spanish_new_clean ,   Survey_Spanish_new_clean
Focus Groups	CMS-10477, CMS-10477, CMS-10477, CMS-10477, CMS-10477, CMS-10477, CMS-10477	Screener for focus group eligibility ,   Discussion guide for focus groups ,   Participant contact release form for focus groups ,   Focus group consent form ,   Screener_Spanish_new_clean ,   Participant_Contact_Release_Forms_Spanish_new_clean ,   Consent_Forms_Spanish_new_clean
Site Visit Interviews	CMS-10477, CMS-10477, CMS-10477, CMS-10477, CMS-10477	Management staff interview protocol and consent ,   Recruitment staff interview protocol and consent ,   Staff educator interview protocol and consent ,   State evaluator interview protocol and consent ,   Clinic staff interview protocol and consent
Stakeholder Interview	CMS-10477, CMS-10477, CMS-10477, CMS-10477	Stakeholder interview appointment reminder ,   Physician interview verbal consent script ,   Stakeholder interview guide and consent form ,   Stakeholder interview scheduling script

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	4,706	4,686	0	20	0	0
Annual Time Burden (Hours)	2,236	1,836	0	400	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The addition of the two Administrative Costs Forms adds two new collection instruments to this package. These forms increase the burden to include 20 more respondents; 400 more total burden hours. The new total burden associated with this information collection is 2,236 hours.

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Annual Cost to Federal Government: $155,126

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/01/2014

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